Inmate grievances are a standard mechanism for prisoners to request changes and express discontent with a variety of conditions of confinement such as housing, officer treatment, and inadequate medical care. Although many in correctional health care see the grievance process as a tedious necessity, inmate medical grievances can be a rich source of information for uncovering system flaws. This patient feedback can actually help improve the quality of your patient outcomes, reduce clinical error, and avoid legal liability. Here are three important ways to use inmate grievances to help provide quality correctional health care.

Fix System Problems

“Last month Doc said I was going for tests about my liver. I haven’t seen my name on the call out list yet. Please help!”

Grievances can sometime unearth major system troubles. A common area of weak systems is the process for outside diagnostic testing. No doubt about it, there is no easy way to get our patients scheduled for a liver biopsy, coordinate officer transport, and the various other arrangements necessary for a successful procedure. The investigation of this grievance revealed that several patient tests had dropped off the log during an extended family leave for the medical unit clerk. Staff turnover can lead to system issues if there are no cross-trained staff to keep processes going. This issue was revealed and resolved through an inmate grievance.

Resolve Staff Issues

“I keep turning in sick call slips but no one will see me in medical. I need some attention right now!”

Sometimes inmate grievances are the result of unreasonable expectations and, after investigation, result in educating the patient about the process of requesting and receiving health care. This request, however, resulted in the discovery that the evening shift nurse, whose post duties included rounding to collect sick call slips, was discarding some slips that she determined were unnecessary to process. Resolving the cause of this grievance may have prevented future patient harm by identifying poor staff behaviors. The immediate result of the investigation was termination of the staff member.

Correct Communication Concerns

“My toe is swollen and infected. I was told I would get better shoes months ago. No one is listening to me.”

This older diabetic inmate rightly needed special foot wear and the state prison system he was in had a good process set up for providing them when necessary. However, the communication between medical and procurement in this particular prison was faulty. Good investigation of this medical grievance revealed the disconnect and initiated a change in communication among facility departments that resulted in faster procurement of medically necessary items such as these shoes.

It can be easy to become tone-deaf to complaints of our patients generated through the inmate grievance process. This is a mistake. Granted, some complaints may be unfounded, but all complaints deserve to be investigated.

To use inmate grievances effectively, a system is needed for investigating grievances, answering them, and tabulating any trends. Here are some tips for a smooth-running grievance process:

Have a designated individual handle all medical grievances. If you are a one-person department, that would be you; however, if more options are available, pick someone who has a genuine interest in patient satisfaction or quality improvement. A single communication point for grievances means relationships can be built among those in the facility most likely to be regularly handling inmate complaints; thus speeding results. This also provides a consistent contact point when addressing issues with the patient population.

Make sure your system is set up to address grievances promptly. Consider grievances like sick call request and turn around a first response in 48-72 hours. A complicated issue may take more time to resolve but you patients should to know they are being heard and that the wheels are in motion.

Categorize grievances related to common quality issues once an investigation of the situation indicates a primary cause. Here are some suggested categories:

o Capacity Issues: Staffing/Supplies

o Communication

o Patient Information/Understanding

o Staff Issues: Knowledge, Accountability, Skill

o System/Process Issues

Tabulate grievance themes in your quality improvement program and investigate trending issues with a formal process or outcome study. Once a trend is seen, a quality improvement study will validate a quality problem and provide baseline data for tracking the outcome of system changes.

Inmate grievances can be a useful source of information about your clinical program. How are you using inmate grievances? Share your experiences in the comments section of this post.

PS – You still have time to get a free downloadable copy of my new ebook – The Correctional Nurse Manifesto – by signing up for my email list. Use this link Hurry! Offer ends July 5!

Are you prepared to handle a mass casualty at your facility? Do you even know what would be considered a mass casualty in your setting? A mass casualty situation could be a natural disaster, illness outbreak, an accident in the inmate shop, or a transport accident. Your facility may house political action groups or gangs who engage in extreme behaviors that lead to group traumatic injury. A prison riots could result in mass casualties. Natural disasters also make the list – Hurricanes or tornados can move through the area. Pandemics such as H1N1 flu can lead to a casualty situation requiring triaging efforts.

Nurses are focused on doing the best for each patient. This value serves us well in most situations. However, doing the greatest good for the greatest number of people is the primary principle in a disaster situation. This might even involve rationing care. Simple Triage And Rapid Treatment (START)is an objective triage tool that was originally developed by the Newport Beach Fire Department and spread throughout the emergency response community. This easy-to-remember and easy-to-perform system is designed to rapidly triage a large number of casualties. In fact, it takes as little as 30 seconds to assess each victim using this process.

An excellent feature is that, with training, anyone can perform a START evaluation; a medical background is not requires. In fact, non-clinicians seem to do this well; possibly because they are less likely to overthink the situation. In triage, we are determining medical need, not providing patient treatment.

Traffic Light System

The familiar Green-Yellow-Red traffic light system is the basis for victim identification. It is important to use the same tag system as the local EMS group for rapid patient hand-offs.

Green – first aid and/or minor medical treatment is needed. These victims may be able to provide self-care or have treatment delayed for hours or days.

Yellow – requires treatment beyond first aid, however, treatment can be delayed for some time.

Red – immediate treatment needed to preserve life – this could mean airway problems, open fractures, or significant bleeding

Expectant – this tag (black) is reserved for those with major wounds that will require significant resources to treat. These individuals will likely die no matter what is done.

START Steps

The priority of disaster casualty management is to preserve the greatest number of lives. Here is a step-by-step guide to the START process.

STEP 0 – Secure the Scene: Scene safety first. This is always true during a correctional emergency. However, in a disaster, there are additional safety issues. For example, there may be another bomb.

STEP 1 – Instruct everyone who can walk to go to a designated area. These are the Green tags

The Respirations/Perfusion/Mental Status evaluation quickly determines if a person needs immediate or delayed attention. In order to be placed into the Yellow (delayed attention) category they need to have:

Respirations less than 30

Capillary Refill (perfusion) less than 2 seconds

Mental Status indicationing that they are conscious and able to follow commands

Victims who do not meet one of these requirements go into the Red (immediate attention) category unless they are not breathing even after opening their airway. In that case, they are considered Expectant (Black).

Here is a flowchart created by CERT Los Angeles that graphically explains the process

Are you prepared for a mass casualty incident at your facility? What do you use for your triage process? Share your experiences in the comments section of this post.

If you are thinking about jumping into the interesting world of correctional nursing you may be looking for employers in all the wrong places. Unlike a traditional healthcare setting, correctional health care units may not be managed in-house, although many are. Below is a primer on various correctional health care management structures.

Governmental Agencies (Self-Operated)

Most correctional nurses do work for the same employer as their custody peers. Currently about 58% of correctional healthcare facilities are in this category. The industry calls this self-operated or self-op. Health care managers in this management structure are a part of the organizational hierarchy and reporting framework. This can be a great advantage for making change or obtaining resources as the health care manager is on parity with other services, therefore fostering support for inmate medical needs. There are disadvantages to this arrangement, as well. Although the well-being of the inmate population is a common goal for both custody and nursing staff, professional frameworks and guiding principles can differ. Nurses in these organizations must be vigilant to maintain professional nursing judgment in all matters of care delivery.

Independent Health Care Service Companies

The next most frequent health care management structures is an independent health care company. Thirty (30)% of correctional health care is provided through a contracted arrangement between the government entity and a health care company. Nurses are most often employees of the health care service company and report to managers within the company. In this situation, correctional nurses need to understand the contractual relationship with the corrections administration to know what may be required of them. For example, services may include providing health care to security staff and emergency treatment to visitors. Also important is an understanding of the communication and reporting structures among all the players. In this situation nurses are guests in the facility and must strive to develop collaborative working relationships with custody staff.

State University Medical Systems

Several state prison systems provide health care to inmates through the state university system. Twelve percent (12)% of correctional healthcare is delivered in this manner. For example, in Connecticut inmates receive care through the University of Connecticut medical system and in New Jersey health care services are provided through the state’s University of Medicine and Dentistry. Nurses working in these systems have the advantage of access to academic resources while nursing, medical, and dentistry students have an opportunity to experience the correctional environment. The corollary in jails is that the county health department may provide the health care at the jail. In this situation nurses have the advantage of access to the resources of the county health department. Although health care staff are not employees of the same entity as corrections staff, a common relationship exists among the government bodies.

Other Correctional Nurse Employers

Nurses may come to practice correctional nursing through other avenues. One area of correctional nursing practice is a locked unit within a community hospital. Hospitals may contract with Departments of Corrections to centralize acute care for inmates. A wing or floor of an acute care facility may be fitted for increased security. All patients on the unit are prisoners from surrounding facilities. Custody officers monitor patients while care is given by nurses employed by the acute care facility.

Nurses may also care for inmate patients as agency or traveling nurses. Many state prisons are located in remote areas far from potential nurse employees. Agency or traveling nurses are engaged for short and long-term assignments at one or several correctional facilities within a system.

So, if you are interesting in trying this nursing specialty, you have a variety of employers to check into. Share your experiences with seeking correctional nurse positions in the comments section below.

Food allergies can be a real challenge for correctional nurses. It is important to document these allergies during intake screenings and put safeguards in place to avoid allergic reactions behind bars. However, inmates can report food allergies that are really preferences (I’m allergic to bologna sandwiches) or food intolerances (I’m allergic to onions). How can true allergies be sorted out from among the many reported?

I recently interviewed Dr. Jeff Keller, correctional physician from Idaho Falls, ID, about the issue on the Correctional Nursing Today Radio Show. This episode is full of interesting and important information for correctional nurses. I highly recommend you download or livestream the 30 minute program. Here are some important points from my notes of the session.

There are IgE mediated and non-IgE mediated allergic reactions. The medical concern is with IgE mediated allergies, which involve immune system mast cells that respond violently to contact with the allergen. Check out this animation to remind you of the IgE allergic reaction process.

Peanuts make up 85% of food allergies. The remaining 15% are from tree nuts and shellfish. Other food allergies such as fin fish or strawberries are rare.

Almost all food allergy deaths happen to teenagers and those in their early 20’s.

Allergic reactions include hives, angioedema and asthma/wheezing.

Ways to test for true allergy include a food confrontation test and skin prick testing. There is also a fairly inexpensive blood test for IgE circulating levels.

Epinephrine is the main treatment for a life-threatening food allergic reaction.

Managing Food Allergies Behind Bars

If an inmate is determined to have a peanut allergy, a peanut-free diet is needed. However, precautions do not end here. Cellmate assignment and work detail must also be considered. This inmate may not be able to be housed with other inmates who have peanut products in their possession. For example, peanut butter and peanut butter products such as sandwich crackers may be available in the commissary. A peanut-allergic inmate may not be able to be assigned kitchen duty if peanut products are present. Shellfish and tree nuts are fairly easy to deal with as pecan-crusted shrimp are rarely on the menu. However, peanut butter is an inexpensive protein source in frequent use in corrections.

Preparing for an Allergic Reaction

A coordinated response to food allergies is needed in every facility. Dr. Keller recommended a protocol be developed addressing actions custody and medical staff will take to respond to true food allergies. Besides diet, housing and work detail issues, a coordinated emergency response to a reaction is needed. Epi pens are the standard mechanism for emergency treatment of an allergic reaction. Inmates are not able to carry needles on their person so the location and accountability for epi pens should be considered. Housing officers may need to have pens available and know how to use them. Correctional nurses may need to provide information and demonstration of epi-pen use. Officers are also likely to be the first responders in an allergy emergency. They need to know the signs of allergic reaction so that they can act quickly to summon assistance and administer epinephrine.

How has your facility dealt with food allergies? Tell us your experiences using the comments section.

Another year is about to roll up and we can look back on plenty of correctional healthcare news from 2011. What top stories from the past year are most memorable to you? Here are my top picks for 2011 game changers along with suggested action to reduce their impact.

#1 Legal eagles rule the roostHealthcare is now the most common legal issue raised by inmates according to a Harvard Civil Liberties Law Review article. The legal system has led the way in correctional healthcare reform even before the landmark Estelle v. Gamble Supreme Court case of 1976. In that case, the Supremes ruled that healthcare was a prisoner’s Eighth Amendment right. Continued case law has further delineated that right. Lack of healthcare, inadequate healthcare, faulty or denied healthcare are frequent claims of inmate defendants. Not only are the costs of healthcare skyrocketing, so are the costs of medical liability insurance. The financial burden of defending against spurious and serious claims is high.

Game changer actions: Do everything you can to strengthen the healthcare delivery system to reduce serious medical claims. This means solid communication and tracking of outside services and diagnostics. In addition, monitor medication delivery and formulary practices. Medication administration is a high risk and problem-prone area of correctional healthcare.

Consider implementing basic customer service principles to reduce spurious legal claims. Closely monitor inmate grievances in this sector. Early intervention can stem later legal cases. Remember, even if a claim is invalidated, legal costs can still be incurred in developing a defense.

#2 Cost shifting along the corrections pipelineAlthough California is the state prison system most in the news about overcrowding, other states are looking for ways to reduce incarceration costs by shifting custody responsibilities to local jurisdictions or mental health services. From a medical perspective, there are renewed calls for improved compassionate release processes.

Game changer actions: Appropriate early release of severely ill and dying prisoners can reduce prison health care costs but burden other systems such as long term care and indigent care services. A practical review of current compassionate release policies and procedures is warrented.

My friend, Sue Smith, MSN, RN, CCHP-RN, spent many years providing nursing care in the Ohio Prison System. Her guest post shares words of wisdom from her work experience.

Maintaining a safe and secure environment is the primary mission of correctional facilities – not healthcare. This means that the persons who hold nearly all of the power in correctional facilities are the security officers and administrators. Practicing within the correctional environment means that correctional nurses must learn to cooperate and collaborate with the security staff. Philosophical differences between the two disciplines can be very significant, especially with regard to treatment of prisoners. One of the most difficult adjustments that correctional nurses must make is learning to work with security staff without sacrificing nursing perspective. Making the adjustment is often difficult, but it can be done. Correctional nurses need to remember a few things:

Security personnel are like most people – they have preconceived notions about how nurses behave and think. Sometimes, correctional staff can be critical of nursing concepts like compassion and patient advocacy, but they still do not like it when nurses do not act as expected. Role modeling expected nurse behavior may invite some teasing, but generally the security staff will have greater respect for the nurses.

Mutual respect will go a long way to facilitate collaboration with security staff. Correctional officers and administrators have a hard job. Correctional nurses need to recognize this and refrain from being overly critical or judgmental about security perspectives about prisoners – without sacrificing their nursing perspective. Simply put – the words “please” and “thank you”, professional courtesy and consideration will help nurses collaborate with their security colleagues.

Nurses need to remember that the correctional environment is different than the hospital environment and can be inherently dangerous. While correctional nurses are not really security staff, they do need to remember and be concerned with safety principles so that they do not place themselves and their security colleagues in unnecessary danger.

What are your experiences with collaboration with our correctional officer colleagues? Share your insights in the comments section of this post.

Attending the Association of Health Care Journalists Conference this week has given many opportunities to consider the application of current health issues and trends to the correctional setting. A discussion of the Affordable Care Act by CMS Director Donald Berwick, MD, in a Newsmaker Briefing does not at first sound like something easily applied to health care in jails and prisons. Centers for Medicare and Medicaid Services (CMS) administers Medicare payments, a payment structure applying to only a small part of healthcare costs in correctional settings. However, his discussion of reducing health care costs could have some application. He stated that our opportunity is to lower cost by improving the care; that the best way to make the care more affordable and sustainable is to improve it. A bit counterintuitive, as first blush, but he goes further. Using the example of technology, Dr. Berwick reminds us that improvements in computers and smart phones came from learning how to make them differently such as using lean production methods. He suggests that these methods can be applied to health care. To apply these principles in healthcare we have to execute properly, which includes removing waste from processes and defects from care. He contends that there are two ways to save money – cut or improve. A lot of talk today is about cutting but Dr. Berwick suggests improvement is a better way.

Can this concept be applied to correctional healthcare? Can we see cost savings by improving the care delivered or the care delivery system? It is an intriguing concept to consider. Generally the thought is that it costs money to improve care. Could it save money? What do you think?